Sepsis Awareness Month

Think Sepsis: Time Matters

Sponsored by:

Sepsis: A Florida Priority

Leading Cause of Death in Hospitalized Patients

(258,000 per year)

Kills more people than prostate cancer, breast cancer

and AIDS combined

Almost 90,000 patients admitted to Florida Hospitals

within Sepsis each year

Cost to treat -- $30,000-$93,000 per patient

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Think Sepsis: Time Matters4

FHA

QIO/

HSAG

ESRD-Region

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Florida College of Emergency Physicians

Sepsis is part of a National Project to

Reduce Patient Harm

Hospital Engagement Network (2015-2016)

QIO Scope of Work

Hospital Improvement Innovation Networks- 2016-2019

Reducing overall harm by 20% and readmissions by 12%

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Some progress but not

enough

Source: HRET Comprehensive Data System, September 1, 2016

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Base-

line

Oct

2015

Nov

2015

Dec

2015

Jan

2016

Feb

2016

Mar

2016

Apr

2016

May

2016

June

2016

FL HEN Rate 11.0 16.9 11.1 14.9 7.7 1.9 11.1 2.1 8.9 3.8

Total HEN Rate 12.5 9.3 8.0 9.3 7.9 6.1 7.9 6.1 8.5 8.0

FL HEN # Hosp. 64 46 46 46 46 46 46 45 44 27

HEN # Hosp. 533 409 414 424 410 403 408 249 217 184

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

18.0

20.0

Ra

te

Postoperative Sepsis Rate

September is Sepsis

Awareness Month

Partnership with QIO/HSAG, FCEP, ESRD Network 7

Toolkit

Webinars

Quarterly forums

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Resources to Support

Preventing Sepsis

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A Patient Story

Abbreviated video (4:39)

http://www.fha.org/files/video/HEN/Sepsis-video.mp4

Full-length video (12:01)

https://vimeo.com/97163230

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SEPSISRECOGNITION

Brian C. Peach, MSN, RN, CCRN

UF Health-Shands Hospital

Medical Intensive Care Unit

University of Florida

College of Nursing

PhD Student

SEPSIS CAN BE CONFUSING….

(Sepsis Survivor, n.d.)

Objectives

• By the completion of this webinar, the viewer will be able to:

• Understand the pathophysiology of sepsis• Discuss differences between the old and new

sepsis definitions• Explain why sepsis epidemiology is flawed• Identify risk factors for sepsis• Recognize assessment findings characteristic of

sepsis and septic shock• Discuss prevention and early recognition

strategies, and future research directions

Sepsis by the numbers

• Now the 10th leading cause of overall death in the United States (U.S.) claiming 220,000 lives annually. (Heron et al., 2009; Joint Commission Center for

Transforming Healthcare, 2014).

• Between 28%-50% of patients who develop severe sepsis in the U.S. die, which is more than prostate cancer, breast cancer, and Acquired Immune Deficiency Syndrome (AIDS)-related deaths combined (Wood & Angus, 2004).

• It is the #1 cause of death in intensive care units in high income countries (Russell, 2006).

• Patients with severe sepsis comprise 10%–40% of intensive care unit admissions (Vincent et al., 2006)

Sepsis by the numbers

• The Agency for Healthcare Research and Quality (ARHQ) reports sepsis is the most expensive condition treated in U.S. hospitals, at a cost of more than $20 billion in 2011(Torio & Andrews, 2013).

• According to the Centers for Disease Control (CDC)’s National Center for Healthcare Statistics, the number of admissions for sepsis climbed from 621,000 in 2000 to 1,141,000 in 2008 (Hall, Williams, DeFrances, & Golosinskiy, 2011).

• The incidence of sepsis increased 8.7% annually between 1979 and 2000 (Martin, Mannino, Eaton, & Moss, 2003).

The Problem

•At present, there is no specific test validated to

diagnose sepsis

•There are no approved drugs that target sepsis

Defining Sepsis

•Sepsis 1: 1991-2001

•Sepsis 2: 2001-2016

•Sepsis 3: 2016-?

Sepsis-1 definition (1991-2001)

• Created in a consensus conference in Chicago by members of the Society of Critical-care Medicine (SCCM) & The American College of Chest Physicians (ACCP)

• They hoped to create a definition that would:• Help clinicians improve detection which would allow for early

therapeutic intervention.

• Aid in standardizing research protocols to improve dissemination and application of research studies.

• The members recognized that the first definition was broad, but the science to define sepsis wasn’t there yet.

(Bone et al., 1992)

Sepsis-1 definition (1991-2001)

• The Sepsis-1 definition was based in the Systemic Inflammatory Response Syndrome (SIRS)

• What is SIRS?

• An inflammatory process related to infectious and non-infectious causes

• Common causes of a SIRS response:

• Infection

• Trauma

• Burns

• Pancreatitis

(Bone et al., 1992)

Sepsis-1 definition (1991-2001)

• SIRS criteria:• T>100.4 F or <96.8F

• HR>90 beats/min

• RR>20 breaths/min

• WBC>12,000 or <4,000 or >10% bands

• PCO2 < 32mmHg

• Sepsis-1 definition:• Infection + 2 or more SIRS criteria= Sepsis

• 3 levels: sepsis severe sepsis and septic shock

(Bone et al., 1992)

Sepsis-1 definition (1991-2001)

(Bone et al., 1992)

REMEDIAL sepsis diagram

(Ttsz, n.d.)

Sepsis-2 definition (2001-2016)

• A second consensus conference held, this time in DC w/ members from the SCCM, ACCP + the European Society of Intensive Care Medicine (ESICM), the American Thoracic Society (ATS), and the Surgical Infection Society (SIS)

• Infection + SIRS is too broad

• They identified a number of biomarkers present during sepsis, but their utility in diagnosing sepsis was still unknown.

• They added clinical criteria for inadequate perfusion to the Sepsis-1 definition: Systolic BP< 90mmHg, serum lactate levels >4mmol, signs of end organ damage

(Levy et al., 2003)

Sepsis-2 definition (2001-2016)

(Ernst, 2012)

Pathophysiology

1. An infectious agent infiltrates the body –

directly into the bloodstream, or the

respiratory tract, GI or GU tract, skin, etc.

2. An excessive inflammatory response leads

to vasodilation, leukocyte accumulation,

increased micro-vascular permeability,

intravascular volume depletion, myocardial

depression, and increased metabolism.

3. This unbridled response leads to an

imbalance between oxygen delivery and

demand, resulting in global tissue hypoxia.

Patients will have abnormally high tissue

oxygen needs primarily due to hyper-

metabolism.(Sandle, 2014)

Newer findings

• Sepsis involves activation of both pro- and anti-inflammatory responses (Hotchkiss, Monneret, & Payen, 2013)

• Recent research has uncovered endogenous factors that rapidly change the cardiovascularneurological endocrine and hematological systems in response to infection and the body’s inflammatory response (Deutschman & Tracey, 2014; Singer, De Santis, Vitale, &

Jeffcoate, 2004).

• These endogenous factors can “amplify” the host response (Singer et al., 2016, p. 804).

• Other factors like the source of infectionscomorbidities and iatrogenic interventions are believed to have a significant impact on the body’s response to infection

Alarmins

• A family of endogenous molecules passively secreted from necrotic tissue cells, injured tissue, activated leukocytes, and epithelia

• Mediate inflammation, and are now one of the targets of therapy research

• Link innate and active immunity

• May prove to be valuable biomarkers in terms of diagnostic and prognostic utility

• Being investigated in relation to autoimmune disorders

• Examples: high-mobility group protein B1 (HMGB1),S100 proteins, and heat shock proteins (HSPs)

(Chan et al., 2012)

(Marker, 2016)

We have a new sepsis definition…

(Farkas, 2016)

The Sepsis-3 definition• In February 2016 the Society of Critical Care Medicine (SCCM) and the

European Society of Intensive Care Medicine (ESICM) announced a monumental change to the sepsis definition at the SCCM annual conference in Orlando, and it was published that same week in the Journal of the American Medical Association (JAMA).

• Why the change?

• 1. Excessive focus on inflammation

• 2. Misleading model that sepsis follows a continuum from severe sepsis to septic shock

• 3. Inadequate specificity and sensitivity of the SIRS criteria

• 4. Multiple definitions are currently used for sepsis, septic shock, and organ dysfunction, which leads to discrepancies in reported incidence and observed mortality.

• 5. The term “severe sepsis” is redundant.

(Singer et al., 2016)

Flawed Epidemiology

There is significant variability in incidence and mortality of severe sepsis depending on how data is collected. Gaieski,

Edwards, Kallan, and Carr (2013) found there is an average annual increase in the incidence of severe sepsis was similar

13.0% to 13.3% across 4 different collection methods. In-hospital mortality however ranged from 14.7% to 29.9%.

(Gaieski, Edwards, Kallan, Carr, 2013)

New Sepsis-3 definition (as of 02/2016)

“Life-threatening organ dysfunction caused by a dysregulated host response

to infection. For clinical operationalization, organ dysfunction

can be represented by an increase in the Sequential [Sepsis-related] Organ

Failure Assessment (SOFA) score of 2 points or more.

(Singer et al., 2016, p. 802)

New Septic Shock definition (as of 02/2016)

“A subset of sepsis in which particularly profound circulatory, cellular, and metabolic

abnormalities are associated with a greater risk of mortality than with sepsis alone. Patients with

septic shock can be clinically identified by a vasopressor requirement to maintain a mean arterial pressure of 65mmHg or greater AND

serum lactate level greater than 2mmol/L (>18mg/dL)in the absence of hypovolemia.

(Singer et al., 2016, p. 802)

What is SOFA?

• A morbidity severity score AND a mortality estimation tool

• Developed from a study of 1,449 patients from 40 intensive care units throughout the world (Vincent et al., 1998).

• The SOFA score is composed of 6 variables, each representing an organ system.

• Each organ system is assigned a point value from 0 (normal) to 4 (high degree of dysfunction/failure)

• The SOFA score ranges from 0 to 24.

• SOFA is superior to the SIRS criteria in terms of predictive validity for in-hospital mortality (Seymour et al., 2016).

What is SOFA?

• Other scoring systems like the Acute Physiologic and Chronic Health Evaluation (APACHE) and Simplified Acute Physiologic Score (SAPS) have only been validated in the first 24 hours of admission, and only to predict mortality (Vincent & Moreno, 2010).

• SOFA should be calculated 24 hours after admission every 48 hours thereafter to assess progress (Vincent &

Moreno, 2010).

• The mean and highest scores are most predictive of mortality (Ferreira, Bota, Bross, Melot, & Vincent, 2001)

SOFA

(Ferreira et al., 2001)

Predicting SEPSIS-related mortality

Maximum SOFA score during ICU stay Mortality

0-6 <10%

7-9 15-20%

10-12 40-50%

13-14 50-60%

15 >80%

16-24 >90%

Based on the results of 2 prospective

studies, SOFA can be used to estimate

mortality in patients with sepsis(Ferreira, et al., 2001; Vincent et al., 1998)

Predicting SEPSIS-related mortality

Score Trend (after first 48 hours) Mortality

Increasing >50%

Unchanged 27%-35%

Decreasing <27%

(Ferreira et al., 2001)

qSOFA

“In out-of-hospital, emergency department, or general hospital ward settings, adult patients

with suspected infection can be rapidly identified as being more likely to have poor

outcomes typical of sepsis if they have at least 2 of the following clinical criteria that together constitute a new bedside clinical score termed

quick SOFA (qSOFA): respiratory rate of 22/min or greater, altered mentation, or systolic blood

pressure of 100mmHg or less

(Singer et al., 2016, p. 802)

(Gonzalez de Castro, 2016)

QSOFA

• qSOFA was found to have a similar predictive validity to a SOFA score outside the ICU

• qSOFA criteria be used to: “prompt clinicians to further investigate for organ dysfunction, to initiate or escalate therapy as appropriate, and to consider referral to critical care or increase the frequency of monitoring, if such actions have not already been undertaken.” (Singer et al., 2016, p. 808)

• The qSOFA can be thought of as a less comprehensive MEWS score. The MEWS contains the three parts of the qSOFA (mentation, RR, BP)+ temperature, heart rate, and WBC

Differences between old and new definitions

• SIRS criteria will soon be out, SOFA/qSOFA scoring will be in. Get to know SOFA and qSOFA!

• The baseline SOFA score is assumed to be 0 in the absence of known organ dysfunction.

• Instead of 3 categories, ‘sepsis’, ‘severe sepsis’, and ‘septic shock’, there are just 2 (no more ‘severe sepsis’)

(Singer et al., 2016, p. 802)

Algorithm using the new sepsis definition

(Singer et al., 2016, p. 811)

Increasing incidence

(Hall et al., 2011)

Why is there an increasing incidence?

An aging population

A rise in chronic disease burdens

Increased usage of invasive procedures

Immunosuppressant medications & chemotherapy

Increased organ transplantation

Antibiotic resistance

Greater awareness and tracking of sepsis

(Centers for Disease Control and Prevention, 2014)

Who’s at risk?

• EVERYBODY!

• ……but especially those with immature, declining, andsuppressed immune systems!!!

• At risk populations: infants, children, older adults, transplant recipients, and individuals with AIDS & cancer(CDC, 2014).

• In one epidemiological study, 71.7% of adult patients with sepsis had cancer, chronic obstructive pulmonary disease (COPD), hypertension, liver cirrhosis, and/or human immunodeficiency virus (HIV) (Martin, Mannino, & Moss, 2006) .

• In the August 26th CDC Morbidity and Mortality Weekly Report (MMWR), the CDC and its partners reported on a retrospective study they conducted of 325 patients in 4NY hospitals.

• 72% of patients had a health care factor during the 30 days PTA or chronic condition that required frequent medical care.

• In 33% of patients, no organism was identified.

• 25% (n=82) patients died

Novosad et al. (2016)

Who’s at risk?

(Centers for Disease Control and Prevention, 2016a)

Signs of sepsis

(Centers for Disease Control and Prevention, 2016b)

Signs of sepsis

• SIRS Criteria:• Temp < 36°C or > 38°C

• HR > 90 beats per minute

• RR > 20 breaths per minute or pCO2 < 32 mmHg

• WBC < 4,000 or > 12,000 or > 10% bands

• Other common signs/symptoms: hypotension (SBP<90 mmHg), change in mental status, decreasing urine output, skin changes

(Fortuna Faveat, 2008)

• Assess for a source of infection• CNS or other source: Mental status changes (could be a CNS

infection, but may be related to a source from elsewhere, particularly in the elderly), e.g. lethargy, obtunded, agitated, anxious, combative, confusion. SUNDOWN PHENOMENON

• Head and neck infection: Inflamed/swollen ear drums, sinus tenderness, nasal congestion/exudate, pharyngeal erythema and exudate, inspiratory stridor, cervical lymphadenopathy

• Respiratory infection: Tachypnea, hypoxia, adventitious sounds, increased sputum production, report of difficulty swallowing/choking with food or fluid intake, increased O2 requirement and/or inhaler/nebulizer use

Assessment

• Assess for a source of infection (continued)

• Abdominal cavity and GI infections: Abdominal distention, localized tenderness, guarding or rebound tenderness, rectal tenderness or swelling, N/V/D

• GU and Pelvic infections: Costovertebral tenderness, pelvic tenderness, cervical discharge, burning with urination, malodorous or cloudy urine

• Skin infections: Wounds, infected incisions, previous line sites

• Assess for signs/symptoms of hypoperfusion• Systolic blood pressure [SBP] <90 mmHg, mean arterial

pressure <70 mmHg, or a decrease in SBP >40 mmHg (baseline SBP may vary)

• HR>90 beats per min• Lactic acid level>2 mmol/L (>4 is severe sepsis)• Obtundation or restlessness• Oliguria or anuria• Warm, flushed skin may be present in the early phases of

sepsis. As sepsis progresses to shock, the skin may become cool due to redirection of blood flow to core organs and/or vasopressor use.

• Weak pulses• Capillary refill > 3 seconds• Mottling (late sign)

End-tidal CO2 monitoring

EMS Sepsis Alerts

EMS-hospital cooperative training

Best-practice alert (BPA) triage systems in EDs

Early warning scores (e.g. MEWS, PEWS, NEWS, MEOWS, qSOFA)

Rapid response teams

Frequent medical, nursing, and allied health staff education

Sepsis audits to identify deficiencies

Prevention Strategies

(CDC, 2016d)

Why is prevention important?

• After or during their ICU stays, septic patients often develop:• Nutritional deficiencies• Repeated infections• Increased energy requirements• Significant organ injury(Gentile et al., 2012)

• Patients who were septic have shorter life expectancy even when controlling for age. Dreiher et al. (2012) found patients’ long term survival was 33%, 23%, and 20%, one, five, and eight years out respectively from the sepsis event.

(Dreiher et al., 2012)

CDC Vital Signs

• A monthly report launched in 2010

• Includes a Morbidity and Mortality Weekly Report (MMWR), a graphic fact sheet and website, a media release, and social media tools.

• The August 26th issue of CDC Vital Signs was about sepsis!

• In this issue, they discussed what is being done at the federal government level, and what can be done by healthcare providers healthcare CEOs/Administrators, state & local health departments, and patients & families

(CDC, 2016c)

CDC Vital Signs: Sepsis

• The federal government is:

• Working to promote and align public health efforts, including: infection prevention, vaccinations, chronic disease management, appropriate antibiotic use, and sepsis prevention and early recognition

• Investigating triggers of sepsis to identify novel prevention strategies and at-risk populations

• Supporting development of new sepsis diagnostic tests and treatments

• Developing more accurate tracking methods to evaluate progress in preventing and treating patients with sepsis

(CDC, 2016c)

CDC Vital Signs: Sepsis

• Healthcare providers can:

• Prevent infections. Follow infection control requirements (e.g., hand hygiene) and ensure patients receive recommended vaccines (e.g., flu and pneumococcal).

• Educate patients and their families. Stress the need to prevent infections, manage chronic conditions, and seek care if signs of severe infection or sepsis are present.

• Think sepsis. Know sepsis signs and symptoms to identify and treat patients early.

(CDC, 2016c)

CDC Vital Signs: Sepsis

• Healthcare providers can:

• Act fast. If sepsis is suspected, order tests to determine if an infection is present, where it is, and what caused it. Start antibiotics and other medical care immediately. Document antibiotic dose, duration, and purpose.

• Reassess patient management. Check patient progress frequently. Reassess antibiotic therapy 24-48 hours or sooner to change therapy as needed. Be sure the antibiotic type, dose, and duration are correct.(CDC, 2016c)

CDC Vital Signs: Sepsis

• Health care facility CEOs/administrators can:

• Make infection control a priority. Ensure a strong link between infection control and prevention, sepsis early recognition, and appropriate antibiotic use programs.

• Train healthcare providers and front-line staff to quickly recognize and treat sepsis.

• Collaborate with health departments and other health care facilities within your area to improve infection control.

(CDC, 2016c)

CDC Vital Signs: Sepsis

• State and local health departments can:• Promote sepsis prevention and early recognition,

vaccination, chronic disease management, and infection prevention in health care facilities and community settings.

• Review actions other states and organizations have taken to improve sepsis early recognition and treatment: http://go.usa.gov/xjxnz .(CDC, 2016c)

CDC Vital Signs: Sepsis

• Patients & families can:

• Learn sepsis signs and symptoms. Know if you are at higher risk. If sepsis is suspected, get immediate medical attention. Ask, “Could it be sepsis?”

• Talk to a healthcare provider about managing chronic conditions and getting vaccines.

• Practice good hygiene, such as handwashing.(CDC, 2016c)

Characterization of population subsets with molecular signatures (e.g. transcriptomic, metabolomic,

proteomic) (Singer et al., 2016)

Development of a gold standard diagnostic test for sepsis, perhaps using biomarkers (Singer et al., 2016)

Epidemiological research based on data collected by clinicians using the Sepsis-3 definition

Additional validation studies of qSOFA

Drug therapies targeted at the sepsis response

This is a 2 part series, and the 2nd

webinar on evidence-based management strategies and the new Centers for Medicare and Medicaid

Services (CMS) sepsis bundle requirements will be held on

Monday, September 26th, 2016, 01:00PM-02:30PM

Shameless Plug

• Topics covered in the 2nd webinar

• The Rivers Trial- Early Goal Directed Therapy

• Results of three large sepsis trials (PROCESS, ARISE, PROMISE) published in the last 2 years

• The Society of Critical Care Medicine’s Surviving Sepsis Campaign

• The Centers for Medicare and Medicaid Services (CMS)’s new sepsis bundles

• Medical management strategies for severe sepsis and septic shock

• EMS and ED-based sepsis initiatives and protocols

FHA Resources

Fire Away!

Evaluation Survey & Continuing Nursing Education

• Eligibility for Nursing CEU requires submission of an evaluation survey for each participant requesting continuing education:https://www.surveymonkey.com/r/sepsis090916

• Share this link with all of your participants if viewing today’s webinar as a group.

• Be sure to include your contact information and Florida nursing license number.

• FHA will report 1.5 credit hour to CE Broker and a certificate will be sent via e-mail.

Thank You!

Contact the FHA HEN Team- HEN@fha.org or 407-841-6230

Kim Streit, VP Healthcare Research and Information

Sally Forsberg RN, Director of Quality and Patient Safety

John Wilgis RRT, Director- Emergency Management Services

Phyllis Byles RN, Quality Coordinator

Debbie Hegarty, Surveys/Specials Project Manager

Luanne MacNeill, Quality Initiatives Coordinator

Allison Sandera, HEN Project Manager

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http://www.cdc.gov/sepsis/datareports/index.html

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http://www.cdc.gov/vitalsigns/sepsis/

http://www.cdc.gov/sepsis/images/sepsis2015-qa-big.gif

http://www.cdc.gov/sepsis/basic/qa.html

http://thebolus.org/sepsis-an-often-missed-diagnosis/

http://emcrit.org/pulmcrit/problems-sepsis-3-definition/

http://fortunafaveat.com/2008/09/10/ive-got-a-fever-the-only- prescription/

http://anestesiar.org/2016/conferencia-internacional- de-consenso-en-sepsis-y-shock-

http://www.cdc.gov/nchs/data/databriefs/db62.pdf

http://www.centerfortransforminghealthcare.org/projects/detail .aspx? Project=8

http://www.labroots.com/trending/microbiology/3720/immune- system-error-creates-

http://

http://www.cdc.gov/mmwr/volumes/65/wr/mm6533e1.htm?s_cid=m m6533e1_w

http://www.pharmamicroresources.com/2014/09/world-sepsis-day.html

https://www.pinterest.com/MsMercedes/sepsis-survivor/

http://www.ncbi.nlm.nih.gov/books/NBK169005/pdf/Bookshelf_NBK 169005.pdf

http://www.thinkstockphotos.com/image/stock-illustration- sepsis/478472486

http://